Management Referral to Occupational Health

Section A – Referring Manager details

Company

Name

Position

Department

Tel No.

Email (required)

Date of Referral

Please confirm the employee has been informed of the reason for referral and what information is being requested.

Confirm

Section B – Employee details

Name (required)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone Number (Home)

Telephone Number (Mobile)

Date of Birth//

Job Title

Department

Location of Post

Email Address

Full Time or Part Time

Full Time
Part Time

Length of time in current position

First day of absence (if applicable)

Section C – Reason for Referral (Please tick)

Checkboxes

Long term health related absence
Advice required regarding information given on a “Fit note”
Persistent short-term absence
Suspected misuse of alcohol and/or drugs
Health concerns related to poor work performance
Review (previously seen by Occupational Health for same health issue)
Return to work assessment following health related absence
Other (Give details below)

Details

Section D – Adjustments

Have any adjustments been made in the workplace to accommodate the employee to date e.g. modified equipment, hours, location, or change of duties etc.

Section E – Specific Questions

What specific questions would you like answering?

Is there an underlying health problem causing the pattern or level of absence?
Does the health problem fall within the Equality Act legislation?
Is additional help or treatment recommended?
When is the employee likely to return to work?
Are any functional limitations recommended?
Does the work environment or duties contribute to the current health problems?
Is a phased return to work recommended?
Is there likely to be a reoccurrence of the same condition in the future?
Other Questions